Provider Demographics
NPI:1952375909
Name:POWELL, BRIAN DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:DOUGLAS
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 HARDING PL
Practice Address - Street 2:STE 3100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00681207RC0001X, 207RC0000X, 207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5921328Medicaid
NC1952375909Medicaid
MN325450000Medicaid
SCNC1671Medicaid
NCNC8187AMedicare PIN
MN325450000Medicaid
MN060001419Medicare PIN
NC5921328Medicaid
MN110210139Medicare PIN